Client Forms

I invite you to: pour yourself a cup of tea, put on some nice music, light a candle or incense, and find a place where you won't be distracted when you fill out your form.

Think of it as a time for reflection, introspection, and self-evaluation. Give yourself enough time and take your time answering the questions; please be as detailed and thorough as possible.

Health History

Welcome! - Your Story of Health

I practice non-judgment and compassion with my clients & all humans, no matter how you identify, look, or where you are in your journey of life, health & healing.
Please share as much as feels comfortable; the more specific + thorough the content, the better!
All information in forms and sessions will be kept confidential between you and me.
Now, take a deep belly breath & let's get started!

Personal Information

Full Name *

Full Name

First Name

Last Name

What name do you like to be called?

Date of Birth *

Date of Birth

MM

DD

YYYY

Preferred Gender Pronoun or Gender *

she / he / they, etc.

Email Address *

Mailing Address

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Best way to get in touch *

Please select your preferred method of communication

Phone

Email

Text

Purpose

First, I invite you to share one or many of the things that are going well for you, things that you are grateful for, or anything positive & uplifting. Celebrate & acknowledge what is good, here: *